Although the general attitude toward methadone and buprenorphine is not favorable on the part of many workers in correctional facilities, the trend is changing. This is partly due to the clear evidence that inmates with opioid use disorders (OUDs), once released, have greatly higher risks of overdosing than the general population, and partly due to several recent cases in which people with opioid use disorders died during forced detoxification without medication.

This fall, the National Commission on Correctional Health Care (NCCHC), in partnership with the National Sheriffs’ Association, released guidelines on medication-assisted treatment (MAT) in jails. And Mark Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD), made the plenary speech at the annual conference of the NCCHC this fall.

The guide, “Jail-Based Medication-Assisted Treatment: Promising Practices, Guidelines, and Resources for the Field,” is important because jails, as shorter-stay facilities, have been less likely than prisons to offer methadone. For the guide itself, go to https://www.ncchc.org/jail-based-MAT.

Kevin Fiscella

Contributors to the guide are Kevin Fiscella, MD, MPH, an addiction medicine expert who serves on the NCCHC board of directors, and is a professor in the department of family medicine at University of Rochester, New York; Andrew Klein, PhD, of the Advocates for Human Potential, Inc.; and Jennie M. Simpson, PhD, of the Office of Policy, Planning, and Innovation at the federal Substance Abuse and Mental Health Services Administration.

Dr. Fiscella talked with AT Forum about the importance of opioid treatment programs (OTPs) in helping correctional facilities move ahead with instituting MAT.

“There’s a huge opportunity for partnership between OTPs and correctional facilities,” said Dr. Fiscella. This is particularly true for current OTP patients. “When someone gets into jail, if the jail personnel are doing what they should be doing, they should be confirming the dose of methadone, and having at least a minimal relationship with the OTP for coordination of care,” he said. Building on this minimal collaboration to a create genuine partnerships could prove mutually beneficial to OTPs and jails.

Getting Methadone to the Inmate

One of the big logistical problems is getting the methadone into the jail—or taking the inmate to the OTP for it. The Drug Enforcement Administration (DEA) is, it is fair to say, obsessed with the security of the methadone, requiring a specialized pharmacy for it (when used for treatment for addiction, not when used for treatment for pain).

Having an OTP in the jail, much like KEEP at Rikers, or the system in Rhode Island, where the vendor operates in facilities, would be best, but most likely this would be impractical in jails across the country.

However, jails have worked with OTPs on records and dosing of existing patients. “If they could build on that partnership, so the OTP does the dosing, then jails could get around the issue of needing an OTP license,” said Dr. Fiscella, noting that this is unlikely to happen in most small county jails, given the cost and logistics. “Most are probably not going to become OTPs, at least not in my lifetime,” he said.

“Short of that, you’re talking about transporting the person, which requires sheriff deputies taking the patient in custody to the OTP,” said Dr. Fiscella. Preferably, though, it could mean the OTP giving the methadone to the deputy, who then takes it to the jail; or having the OTP transport the methadone to the jail.

Stopping Methadone at the Time of Arrest: “Barbaric”

Early in his career, Dr. Fiscella was medical director of an OTP. “I was struck by the fact that as soon as someone got arrested, their methadone was abruptly stopped,” he said. “It was barbaric. I saw patients who evaded their warrant because they were terrified of jailhouse detox, of withdrawal.”

With an OTP, every drop of methadone has to be accounted for. It’s never clear when someone will be released. There are tracking problems. Methadone stored in jails can be diverted—even by jail staff. Some states, such as Vermont, have overcome these challenges.

Pregnancy Is a Different Situation

If the inmate is pregnant, this relationship is particularly important. Even jails that don’t otherwise offer agonists will often offer them during pregnancy, because of the risk to the fetus in withdrawing from opioids on which the mother is dependent. Typically, workers in jails and prisons who care for inmates (custodial staff) are opposed to agonists, thinking of them as merely prolonging an addiction. But when it comes to the babies, they are more willing to work with OTPs. These partnerships involving pregnant inmates can potentially be expanded to all inmates with OUD.

“Even in the minds of some hardened custodial staff—more sympathy for the fetus than the woman,” said Dr. Fiscella.

“There are jails that will use opioids, including methadone, to treat the pregnant woman, and believing it is legal, because they’re not treating the mom, they’re treating the fetus,” added Dr. Fiscella. A better alternative to meeting the needs of pregnant inmates is provide treatment through partnerships that fully conform with DEA regulations.

How OTPs Can Help

The time has come for OTP leadership to reach out to the local sheriff, for their own current patients, and for any possible new patients who could be admitted via the correction health system, said Dr. Fiscella. “Ask, ‘What can we do to work together better?’ Having those face-to-face meetings is crucial.”

Remember, though, that the biggest problem is that the OTP and the Sheriff are part of two extremely different, siloed institutions. “And now we’re asking them to begin collaborating, when they’re both inherently suspicious of the other.” Overcoming this mistrust takes time and persistence.

What About Buprenorphine and Vivitrol?

As for buprenorphine, there’s already a lot of mistrust because the Suboxone strips have been so easy to smuggle into jails, said Dr. Fiscella. Never mind that the reason that they are being smuggled in is to treat the inmates with OUDs who are sick (i.e., withdrawing). Other forms of buprenorphine might help mitigate these concerns.

Some sheriffs think that a two-week detoxification with buprenorphine is a humane way to treat opioid-dependent new inmates. But maintenance treatment is better. One way to convince the sheriff to work with the OTP is to explain the high risk that people will die of an overdose when they leave the facility. Neither jails nor OTPs want to see anyone die from opioid overdose. This common interest can become the foundation for partnerships.

Finally, Vivitrol, a favorite among many correctional workers because it is not addictive, is going to be difficult to for OTPs to fight. Dr. Fiscella concedes this. In fact, OTPs do treat patients with Vivitrol, and can help supervise the humane detox that can take place in jail, transferring people to Vivitrol when they leave. The challenges with this are, 1) most patients would prefer methadone or buprenorphine, and in this country, patient choice counts; and 2) if the patient doesn’t get repeat Vivitrol shots after discharge, he or she is just as likely to overdose as the patient who is put on abstinence-only treatment after hard detox in jail.

This is the story of a young woman with a 15-year history of severe opioid use disorder (OUD), intermittent hospitalization, and incarceration, who becomes pregnant. She has a history of trauma and mental health issues, and few social supports. Her story is the subject of a case report recently published in the Journal of Addiction Medicine.

It’s well known that methadone, in adequate doses, helps to keep pregnant women in treatment and reduces the risks of illicit drug use and overdose. Across the country, some—but not all—corrections facilities will continue pregnant women on opioid agonist treatment. Overall, most correction facilities fail to follow evidence-based treatment guidelines for OUD.

When people with OUD are incarcerated, “methadone is generally stopped immediately—without a taper,” Jessica Gray, MD, lead author on the report, told AT Forum. “Opioid agonists are life-saving treatments that shouldn’t be withheld or limited when people are incarcerated, but outside of Rhode Island and a few other facilities, like Rikers, that’s not the case,” she added. Even jails that do provide methadone treatment for pregnant women generally fail to continue methadone when women return to jail after giving birth, according to Dr. Gray, who works at Massachusetts General Hospital and completed a fellowship in addiction medicine at Boston Medical Center.

The Patient’s Early History

The patient began using illicit medications at age 13 to self-medicate anxiety and depression. She attended a methadone program sporadically. While hospitalized for a benzodiazepine and opioid overdose, she learned that she was pregnant.

Pregnancy

The months that followed were marked by repeated emergency department visits, hospitalizations, and incarcerations. The patient failed to return for prenatal care, despite follow-up appointments and outreach calls.

Emergency department visits: 6+

Hospitalizations: 3

Incarcerations: 3

Prenatal visit: 1 (while incarcerated)

She had bouts of sedation, probably due to the effects of “methadone treatment combined with illicit benzodiazepines, gabapentin, and clonidine,” the authors of the study believe. She also had pneumonia, a urinary tract infection, a broken arm (from falling), abdominal trauma (after an assault), a potentially life-threatening kidney infection, and a weeklong hospital stay related to abnormalities seen on the baby’s heart monitor. And she was HCV-positive, with a high viral load, indicating an infection that she could pass on to her baby.

According to a study by Kelsey and associates, examining national jail policies in the U.S:

Almost half of all pregnant women with OUD in U.S. jails went through withdrawal without the help of opioid agonists or similar medication

This patient was one of the lucky pregnant women whose methadone treatment was continued per protocol while she was in jail.

Giving Birth

The patient was in jail and at term when labor began. She was taken to the hospital to have her baby. Her shackles were removed, but she was barred from contacting someone to be with her during labor. A corrections officer was posted in the hall outside her hospital room. As distressing as this sounds, Dr. Gray told AT Forum that some institutions still keep women shackled or restrained during labor, with a guard posted inside the room.

Because the woman was incarcerated when she gave birth, the newborn was taken away, and the mother’s custody rights were immediately suspended.

The infant, a son, was healthy and born at term—despite the mother’s lack of prenatal care, and her intermittent use of illicit substances during pregnancy. This was likely thanks in part to her continued treatment with methadone throughout her pregnancy.

Standard care at the woman’s jail is to abruptly stop methadone treatment after a woman gives birth, but the patient’s team—the authors of the study—convinced jail authorities that this would increase the patient’s risks of overdose and relapse post-release. So her methadone treatment continued in jail during the months postpartum, and eventually she was released from incarceration

Jails and OTPs in Alliance

Clearly, a need exists for jails and OTPs to work together to help women like this patient. But how to facilitate it?

According to Kevin Fiscella, MD, MPH, a board member of the National Commission on Correctional Healthcare (NCCHC), some jails have OTP licenses in place, but most need to partner with a community OTP.

Partnering is easier than it sounds, because usually a relationship already exists, Dr. Fiscella told AT Forum. “People come into a jail already taking methadone or buprenorphine, prescribed by an OTP, and the jail personnel need to know the dose.”

Dosing information and the dosing history are especially important for pregnant prisoners. As the pregnancy progresses, women may need higher doses in order to prevent withdrawal. So OTPs want jails to have the dosing information. They, and the jails, want treatment to continue, to protect not only pregnant patients, but all patients from the risks of overdosing once they leave jail.

This collaborative relationship isn’t difficult to establish, but it’s not very common—creating an opportunity for jails to expand their relationships with community OTPs, thus improving care.

The Silo Effect

The situation Dr. Fiscella described works well, but achieving it isn’t always without problems.

Dr. Gray described the treatment system for patients with OUDs as “broken” in some ways, and operating “in silos” that limit interactions. “OTPs are heavily regulated, not part of the mainstream health system or community organizations,” she explained. “Our corrections system is another silo. The more we can get out of these silos and engage our community partners and collaborate as teams the better we can understand complex treatment issues.”

The relationship can be developed either in a crisis, or ahead of time—so people know they can rely on the other entity, the OTP or the hospital, in the future.

“Understanding the safety, logistical, or other concerns and needs of the systems you work with is critical. Working across organizations to address those issues can improve the experience and comfort of all parties, such as in this case providing education and support to nursing staff around methadone in the jail.” You need to support each other, she added, pointing to the current case as a good example of what collaboration can do.

We asked Dr. Gray what OTP personnel can do to help other women facing these challenges. Are counselors—or management—most effective in communicating with jails?

Both, Dr. Gray said, for she sees a role for individuals and groups at all OTP levels. Members of a multidisciplinary team can choose the person best suited to present the message to the house of correction, but everyone can impact change. The idea is to create formal and informal partnerships, and make those relationships work—even before a crisis exists.

One Patient Can Make a Difference

“Advocacy can start on an individual level”, said Dr. Gray, “and in this case was used to change the local landscape for women with opioid use disorder who deliver in jail.” The Case Report patient transitioned from being at an incredibly high risk for a bad outcome, to turning her life around.

Dr. Gray later met another pregnant woman in similar circumstances—a woman who wasn’t afraid of what she faced, because of the team’s groundwork with the woman in the Case Report. Dr. Gray was deeply moved to have made such an impact. “The hope is that the precedent you set in providing evidence-based treatment behind bars will positively impact the treatment of future incarcerated patients.”

A Remarkable Change

The new mother discussed earlier in the Case Report underwent a remarkable change after giving birth, Dr. Gray told AT Forum.

There’s no way to know if the change will be permanent, but Dr. Gray is optimistic. “The more that evidence-based treatments (such as opioid agonist medications) are provided, the more likely our patients will survive long enough to be successful.”

In a far-reaching policy paper to be published next year, a draft copy of which was obtained by AT Forum, the American Association for the Treatment of Opioid Dependence (AATOD) takes stock of the increasing prevalence of opioid use disorder (OUD). “Medications Used to Treat Opioid Use Disorder: Learning from Past Lessons to Guide Policy,” by Mark Parrino, MPA, AATOD president, discusses the current state of methadone maintenance treatment,

The overdose epidemic started with prescription opioid misuse and transitioned to heroin use; now, illicit fentanyl is the main substance involved in overdoses.

The question is, what can opioid treatment programs (OTPs), the AATOD members, do to help?

The treatment system, including OTPs and DATA 2000 (office-based buprenorphine prescribers) is expanding. The criminal justice system is increasingly involved, and there is a greater interest in treatment of OUDs in prisons and jails.

The policy paper asks key questions, including:

Should we view treating OUD as a public health intervention, with the principal component of care utilizing federally approved medications (methadone, buprenorphine, and Vivitrol/naltrexone)?

Should we devote resources to treating this disorder with medications and additional clinical services?

Should we better-coordinate organized service delivery to treat this illness through a continuum of service delivery components?

Should there be a better connection between DATA 2000 practices and OTPs, to facilitate referrals from one practice to the next?

The Meaning of “Assisted”

The very phrase Medication Assisted Treatment (MAT) suggests that medication alone is not sufficient to treat the complex disorder, the policy paper notes. Indeed, the National Institute on Drug Abuse says this in “Principles of Drug Addiction Treatment,” as does the Substance Abuse and Mental Health Services Administration (SAMHSA), in its “Treatment Improvement Protocol #43: Medication Assisted Treatment for Opioid Addiction in Opioid Treatment Programs.” The AATOD policy paper notes this also.

The policy paper includes a brief description of the early history of the development of methadone maintenance, and a discussion of the value of providing comprehensive treatment services.

History

The policy paper also goes through a history of MAT. One point was made by Vincent Dole, MD, who postulated that “the high rate of relapse of addicts after detoxification from heroin use is due to persistent derangement of the endogenous ligand-narcotic receptor system, and that methadone, in an adequate daily dose, compensates for this defect.” While some patients can do well after treatment is terminated, the majority do not, he wrote. “The treatment, therefore, is corrective but not curative for severely addicted persons.”

OTPs with methadone were developed through a closed panel system following regulation by the Food and Drug Administration (FDA) in 1972. However, the first compendium of clinical guidelines was not published until 1993, through SAMHSA’s first “Treatment Improvement Protocol State Methadone Treatment Guidelines.”

Oversight

Then there was the General Accounting Office Report of 1990: “Methadone Maintenance—Some Treatment Programs Are Not Effective; Greater Federal Oversight Needed.” Although the FDA had regulatory oversight, along with the Drug Enforcement Administration (DEA), the GAO found that the FDA’s oversight was inadequate. After this, regulations became stricter.

The policy paper also cites the findings of John Ball, PhD, that a significant determinant of the effectiveness of methadone maintenance on reducing IV drug use and needle sharing is long-term retention, along with high rates of attendance, and an enduring relationship with staff.

The bottom line point here is that the program characteristics are more important in determining patient outcome than pre-treatment patient characteristics, writes Mr. Parrino.

And a key point is that these findings are equally applicable to DATA 2000 practices—or should be, although there is little research about what DATA 2000 practices are doing, compared to OTPs.

In 2001, SAMHSA took over regulation of OTPs, using accreditation to monitor quality assurance. The National Commission on Correctional Heath Care implemented similar accreditation procedures for treatment in correctional settings.

Diversion

The paper goes on to discuss problems of diversion, noting that the biggest problems occurred when physicians started to prescribe methadone to treat pain. Take-home methadone from OTPs has much greater restrictions than pain medications do.

With the advent of DATA 2000 practices and buprenorphine, however, the value of oversight seemed to be “forgotten,” writes Mr. Parrino.

The decision not to have any federal oversight for DATA 2000 practices was driven by several variables, he writes. The first was the attempt to normalize addiction treatment so that clinical practitioners could treat this illness without the regulatory burden that had been implemented for OTPs.

AATOD agrees with making standards of care required as a method of guiding clinical care in DATA 2000 practices, based on the history of treating this disorder with medications, writes Mr. Parrino.

Care Coordination

The policy paper also discusses the importance of care coordination, which includes models such as the Vermont Hub and Spoke system, with OTPs as the hubs and DATA 2000 practices as spokes. This model has been very successful.

“There are large states that could certainly benefit from the coordinated models, by breaking them into counties or municipalities,” writes Mr. Parrino. “The point is that coordination of care is critically necessary as first responders save an individual from overdose through the administration of Narcan [naloxone]”, getting the individual to an emergency department, where trained personnel can get the person evaluated and referred to treatment.

Mark Parrino

Finally, the paper focuses on the emerging importance of the criminal justice system, citing positive initiatives in Connecticut and Rhode Island, in particular, where OTPs are operating within prisons and jails. The results from both state experiences is a significant reduction in recidivism: individuals do not return to the correctional system, and there is a dramatic reduction in opioid mortality, writes Mr. Parrino. That’s what happens when inmates are released to community-based practice settings, and smoothly transition into the OTP to continue their treatment, he said. Without question, this kind of intervention should be repeated throughout the United States, so that inmates with OUD can have access to treatment during incarceration, and referred to outpatient treatment facilities upon release.

“Inside Rhode Island’s Adult Correctional Institutions in this Providence suburb, while facing a felony charge of drug possession with intent to deliver,Roussell was offered a chance to break his addiction through a groundbreaking new program. “I was very surprised to find out that I was able to have methadone in prison,” he says.

Every day while locked up, Roussell drank a 55-milligram dose of methadone, the medicine doctors have used for 50 years to help people get off heroin. “It was very comfortable, very helpful,” says Roussell.

Roussell got treatment for his addiction in prison because, two years ago, Rhode Island decided to do something no other state has done. In 2016, it began offering its prison inmates all three medications approved to treat opioid addiction: methadone, Suboxone, and Vivitrol. About 350 Rhode Island prisoners each month take one of the three medicines. Crucially, they continue their treatment after their release, usually through the state’s Medicaid program, when they’re at the greatest risk of a relapse and a fatal overdose.”

“For almost 80 percent of inmates, life after release often lands them back in prison. For others, that “revolving door” stops with a fatal drug overdose, usually days after their sentence ends, researchers said.

Within the first two weeks of their release, former inmates were 40 times more likely to die of an opioid overdose than an average citizen, a study published Thursday in the American Journal of Public Health found.

The risk of fatal opioid overdose was highest among male white prisoners ages 26 to 50, especially those who had served more than two previous sentences and received substance abuse and mental health treatment during past terms.”

“More than half of Americans who have a prescription opioid use disorder or use heroin have had contact with the criminal justice system, a retrospective cross-sectional analysis suggests.

And as the intensity of their opioid use increased, so did their involvement with the criminal justice system, reported Tyler Winkelman, MD, MSc, of Hennepin Healthcare in Minneapolis, and co-authors in JAMA Network Open.

The study included 78,976 respondents — 42,495 women and 36,481 men — representing 196,280,447 adults in the U.S. In the 12-month period:

2% (124,026,842 adults) reported no opioid use

3% (61,462,897 adults) reported prescription opioid use

3% (8,439,889 adults) reported prescription opioid misuse

8% (1,475,433 adults) reported prescription opioid use disorder

4% (875,386 adults) reported heroin use

People who reported any level of opioid use were significantly more likely to be white; have low income; and report a chronic condition, disability, severe mental illness, or co-occurring drug use than were individuals who reported no opioid use.

As the level of opioid use rose, involvement in the criminal justice system (excluding minor traffic violations) climbed. History of criminal justice involvement was associated with:

“The top Massachusetts court unanimously ruled on Monday that a judge can require defendants with substance use disorders to remain drug-free as a condition of probation and send them to jail if they relapse.

The case, which challenged a requirement routinely imposed by judges across the country, had been closely watched by prosecutors, drug courts and addiction medicine specialists. For many, it represented a debate over the nature of addiction itself.

The defense argued that addiction is a chronic, relapsing brain disease that compromises an individual’s ability to abstain. The prosecution maintained that addiction varies in intensity and that many individuals have the ability to overcome it and can be influenced by institutional penalties and rewards, like incarceration or a cleared criminal record.

While acknowledging the numerous experts who weighed in on each side, the seven justices of the Massachusetts Supreme Judicial Court declined to take a stance in the debate. Instead, they said, the defendant in the case should have raised the issue when her probation condition was first imposed, when it could have been fully argued before a trial judge.”

“State prisons across the U.S. are failing to treat at least 144,000 inmates who have hepatitis C, a curable but potentially fatal liver disease, according to a recent survey and subsequent interviews of state corrections departments.

Many of the 49 states that responded to questions about inmates with hepatitis C cited high drug prices as the reason for denying treatment. The drugs can cost up to $90,000 for a course of treatment.

Nationwide, roughly 97 percent of inmates with hepatitis C are not getting the cure, according to the survey conducted for a master’s project at the Toni Stabile Center for Investigative Journalism at Columbia University’s Graduate School of Journalism.

Advocates say this ignores a 1976 Supreme Court ruling that determined an inmate’s medical care is a constitutional right.”

“The inmates filed into a room at a New York prison, squeezed into classroom-style desks, and watched a guard demonstrate how a small plastic tube could help them save lives when they return to the streets of a nation gripped by an opioid epidemic.

The weekly class at the Queensboro Correctional Facility in New York City is part of a state program to expand access to naloxone, a drug delivered through a nasal spray that can quickly revive someone who is overdosing on heroin or an opioid-based prescription painkiller.

By giving naloxone kits to inmates upon their release, New York state officials hope those in need will have a better chance of getting the antidote in time.”

“This month, the House and Senate will be marking up dozens of opioid-related bills, some of which attempt to expand access to the triad of Food and Drug Administration–approved medications to treat opioid addiction: methadone, buprenorphine, and injectable naltrexone. As physicians who have helped thousands of people sustain their recovery with these proven medications, we welcome enhanced funding and access to them. At the same time, we lament the reality that many of the people with opioid addiction who are among those at highest risk of death are unlikely to receive them: those in jails and prisons.

Drug use is concentrated in the corrections population. At least a quarter of the nearly 2.3 million Americans currently incarcerated are addicted to opioids. Between a quarter and one-third of the nation’s heroin users pass through correctional facilities each year. And their eventual release to the community is a time of high vulnerability.”